Organic Exemption Request Form Popcorn Board

OMB No. 0581-0093

The information on this form is required to make a determination concerning a person’s eligibility for exemption from 

assessments under research and promotion programs.

 

Type of Operation:  Processor

Please complete the following: 

Applicant’s First and Last Name:

Company 

name: Phone:

Street 

address: Fax:

City/State/Zip 

code: E-mail:

Tax ID # Importer 

ID #

In order to be exempt, the above-named company must meet all of the following (please check):

 

 Operates under an approved organic system plan authorized under the USDA-AMS organic 

regulations (7 CFR Part 205) and maintains a valid organic certificate issued by an AMS 

accredited certifying agent.

 Processes products eligible to be labeled “organic” or “100% organic” under the USDA organic 

regulations. 

 Is subject to assessments under the research and promotion program for which this exemption 

is requested.



A copy of this company’s organic farm or organic handling operation certificate and 

addendum provided by a USDA-accredited certifying agent under the OFPA must be

attached. 

Certification Statement 

I hereby certify that my annual processing and distribution of popcorn is an estimated total 

___________ hundredweight, with _____________ hundredweight “organic” and/or “100% organic” and 

___________hundredweight non-organic (or conventional). 1 (Organic and non-organic hundredweight 

should equal total hundredweight)

____________________________ _____________________________ _____________

Signature Title Date

1/ Any false statement or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than 5 years or both 

(18 U.S.C. 1001).

Please submit this form via: 

 

 

Popcorn Board

330 North Wabash, Suite 2000

Chicago, IL 60611

Phone: (312) 673-4883

Email: gbertalmio@popcorn.org

AMS-15 (Rev. 4/17) Destroy previous editions. See reverse for burden/non-discrimination statement
NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as 

amended. The authority for requesting this information to be supplied on this form is from the applicable commodity legislation for research and 

promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification 

Number (TIN) or importer identification number is mandatory and will be used to determine affiliation or entity identity.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection 

of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0093. The 

time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 

information. 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its 

Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on 

race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, 

family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in 

any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by 

program or incident. 

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American 

Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA 

through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 

http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of 

the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to

USDA by: 1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW 

Washington, D.C. 20250-9410; 2) fax: (202) 690-7442; or 3)email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.